Provider Demographics
NPI:1891806121
Name:BONILLA, EDWIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:R
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-5308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 W 8TH ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-5507
Practice Address - Country:US
Practice Address - Phone:337-463-8977
Practice Address - Fax:337-462-3093
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1913324Medicaid
LA1913324Medicaid
LADO8564Medicare UPIN